Obliteration Of Space Research Articles

Local muscle flaps via video-assisted thoracoscopic surgery (VATS) without thoracotomy for dead space obliteration

The obliteration of intra-thoracic dead space following tumor or empyema extirpation is imperative to successful long-term outcomes. We sought to describe the technique of using a pedicled latissmus dorsi muscle flap for obliteration of a large 14 × 6cm intrathoracic dead space following pleural decortication of chronic empyema, without thoracotomy or rib spreading via video-assisted thoracoscopic surgery (VATS). Specific attention is directed to the technical details of the flap harvest and inset in relation to the modifications required to inset the flap without a thoracotomy or rib spreading. The patient’s history, presenting symptoms, pre-operative imaging, intraoperative details, and post-operative course are delineated with a focus on the length of stay, post-operative pain, and morbidity. The length of stay was 2 days with minimal pain on post-operative day one managed with oral nacrotic; long term post-operative X-ray revealed obliterated dead space and the patient experienced no complications. Inset of pedicled latissmus muscle flaps via VATS technique without thoracotomy or rib spreading seems a safe and effective technique that can offer short hospitalization with minimal pain morbidity.

Prosthetic Mesh for Obliteration of the Nephrosplenic Space in Horses: 26 Clinical Cases

To report surgical complications, occurrence of post-obliteration colic, long term outcome, and return to previous function for horses treated with prosthetic mesh obliteration of the nephrosplenic space. Retrospective study. Horses (n = 26) having nephrosplenic space obliteration using prosthetic mesh. Horses undergoing mesh obliteration between January 2006 and May 2013 were included. A Proxplast™ mesh was secured to the nephrosplenic space with titanium helical coils in standing horses using laparoscopic technique. Perioperative data were obtained from the medical record and by telephone followup. Tests of proportion were used to compare the study population to the hospital colic population. Occurrence of colic within 1 year of obliteration was compared between horses where the diagnosis was confirmed at laparotomy and those diagnosed by abdominal palpation per rectum using a Fisher's exact test. All 26 horses undergoing mesh obliteration during the study period survived to discharge. Long term followup was available for 25 horses, with 23 returning to their previous level of function, and 21 alive at the time of followup. Cause of death was not associated with the surgical procedure in any case. Geldings and Warmbloods were overrepresented compared to the hospital colic population. Ten horses (38%) demonstrated colic after mesh obliteration. All 10 horses were examined by a veterinarian and none were diagnosed with recurrence of nephrosplenic entrapment. Mesh obliteration of the nephrosplenic space is an effective alternative to suture closure for preventing nephrosplenic entrapment of the large colon in horses. No complications related to mesh obliteration were reported in our study population.

Evidence-Based Abdominal Wall Reconstruction: The Maxi-Mini Approach.

Complex abdominal wall reconstruction is a high-risk procedure, but it can be performed safely if a systematic approach is followed. In this article, the authors present their evidence-based technique for abdominal wall reconstruction. This approach aims at reducing rates of complications and hernia recurrence, starting with critical patient selection; preoperative patient optimization; adherence to intraoperative principles including preservation of vascular perforators through maintenance of composite tissue with limited undermining; direct supported mesh reinforcement of midline musculofascial reapproximation; use of percutaneous transfascial suture mesh fixation; careful attention to dead space obliteration in any plane; and aggressive soft-tissue resection of marginal, undermined, or tenuous skin and subcutaneous tissue. Postoperative strategies to decrease complications are also used. The authors' surgical technique is described in detail, and pilot data are presented to support the authors' approach.

Composite orbital reconstruction using the vascularized segmentalized osteo-fascio-cutaneous fibula flap

Reconstruction of composite orbital defects must address the orbit and an exposed skull base and/or maxillary region. The orbit should not only be covered but also reshaped to accommodate the orbital contents or an epithesis when warranted. This study presents a rationale for a near-anatomical reconstruction of the orbit, together with adjacent dead space obliteration, using the segmentalized osteo-fascia-cutaneous fibula flap. Before the flap transfer, a cutting template for the fibula is made according to the measures and requirements of the facial defect. The segmentalized bone is then osteosynthesized to the facial skeleton and revascularized. Thus, an orbital depth is created by the bony fibula, whereas the fascio-cutaneous part of the flap may be used for lining the orbit and obliteration of the skull base or the maxillary region, or resurface the palate and/or the nasal cavity.

Reply: “Composite orbital reconstruction using the vascularized segmentalized Osteo-Fascio-Cutaneous Fibula flap”

Reconstruction of composite orbital defects must address the orbit and an exposed skull base and/or maxillary region. The orbit should not only be covered but also reshaped to accommodate the orbital contents or an epithesis when warranted. This study presents a rationale for a near-anatomical reconstruction of the orbit, together with adjacent dead space obliteration, using the segmentalized osteo-fascia-cutaneous fibula flap. Before the flap transfer, a cutting template for the fibula is made according to the measures and requirements of the facial defect. The segmentalized bone is then osteosynthesized to the facial skeleton and revascularized. Thus, an orbital depth is created by the bony fibula, whereas the fascio-cutaneous part of the flap may be used for lining the orbit and obliteration of the skull base or the maxillary region, or resurface the palate and/or the nasal cavity.

Pseudomeningocele With Orbital Extension as a Complication of Fronto-Orbital Advancement and Remodeling in Craniosynostosis.

The authors present a series of patients who developed a pseudomeningocele following fronto-orbital advancement and remodeling (FOAR), describing clinical presentation, investigations, and management. Risk factors are identified and preventative strategies suggested. From 2002 to 2012, all patients who underwent FOAR at our unit were identified. Those who developed a pseudomeningocele were selected and case notes, scan imaging and photographs were reviewed. Two hundred thirty-six FOAR operations were carried out over 12 consecutive years. Sixty-one of these patients were syndromic. A pseudomeningocele occurred in 6 patients. All affected cases were syndromic. Clinical features of presentation with orbital pseudomeningocele included orbital swelling, ptosis, proptosis, and/or hypoglobus. Raised intracranial pressure (ICP) was managed before pseudomeningocele repair in 2 patients, at the time of pseudomeningocele repair using an extra-ventricular drain (EVD) or lumbar drain in 4 patients. Decompression of the pseudomeningocele with excision and duraplsty was carried out in 5 patients, 1 patient required excision of gliotic brain and obliteration of dead space. Four patients had a calvarial graft to manage the bony defect and a further 2 had a titanium mesh. None of the patients had a recurrence of the pseudomeningocele or any long-term ocular or aesthetic complications. Pseudomeningocele has not previously been described in FOAR, but in a large series of consecutive patients, we have identified a 2.5% incidence. This incidence increases to 10% in the syndromic population of patients undergoing FOAR. The risk factors include a diagnosis of syndromic craniosynostosis, dural tear, hydrocephalus or raised ICP, infection, persistent cerebrospinal fluid (CSF) leak, or presence of dead space. Preventative strategies include CSF management before or post-FOAR. The ultimate treatment of the pseudomeningocele and growing fracture involves surgical decompression of the collection, a duraplasty, reconstruction of the orbital roof, and temporary CSF diversion.

P021. Investigation on occipital headache associated with vertigo and vomiting discovers a familial clustering of Chiari I malformation and a “puzzle”

A 16-year-old male (patient 4) experienced an episode of bilateral parietal headache, preceded by vertigo and associated with vomiting, lasting about two weeks. An MRI scan performed for a subsequent episode of occipital and neck pain with vomiting and vertigo showed an imaging to the limit of Chiari I malformation (CMI): cerebellar tonsils below the foramen magnum, not reaching posterior arch of C1, but with obliteration of peribulbar posterior liquoral space, cyst septum pellucidum and cavum vergae. Left facial nerve palsy at the age of 12, frequent alimentary vomiting and abdominal pain, episodes of exercise-induced asthma although not confirmed through respiratory tests, were found in the patient's history. An MRI was performed on his father for otoneurological symptoms characterized by a recurrent sensation of disequilibrium when suddenly changing position, on one occasion preceded by a sensation of right ear pressure (diagnosed as sudden hearing loss). Two years ago he experienced an episode of stabbing occipital headache with shoulder pain irradiation, nausea and phonophobia. The MRI revealed cerebellar tonsils slightly below the foramen magnum, to the limit of CMI. MRI was performed also on his mother (patient 1), who suffers from tension-type headache even for long periods of time (months), showing no alterations, and on his 21-year-old brother (patient 5) suffering from episodic tension-type headache, showing cerebellar tonsils slightly below the foramen magnum, to the limit of CMI. His mother's interview revealed that her sister (patient 3) has five sons, two of them with CMI: 1) a 13-year-old male (patient 7), suffering from West syndrome, who at 3 years of age had an MRI that showed approximately 10 mm caudal descent of cerebellar tonsils with a reduction of the liquoral flow at the craniocervical junction and associated syringomyelia extending from C6 to D2 vertebral body; 2) a 26-year-old female (patient 11) with a cerebellar tonsils extending 11 mm below the foramen magnum, associated with posterior fossa hypoplasia. The “puzzle” comes from the fact that both the husbands of the two sisters (patients 1, 3) have the same surname but with no recognized relationship. The doubt seems to be resolved by the MRI performed on the 34-year-old daughter (patient 6) of the third sister (patient 2) showing slight tonsillar descent but without obstacle to liquoral flow (Figure ​(Figure11). Figure 1 oval = female, rectangle = male, shaded = tonsillar descent diagnostic or to the limit of CMI, ? = MRI not performed This report adds to other descriptions of familial clustering of CMI malformations, which suggest an underlying genetic basis. Written informed consent to publish was obtained from the patient(s).

Walking suture na redução de um amplo espaço morto secundário a uma mastectomia canina – relato de caso

Mastectomy is the treatment of choice for tumors of the mammary gland. Since infiltrative tumors with expansive ulcerations are more aggressive, problems may occur in surgical synthesis due to lack of skin to close the wound. A walking suture was used to reduce de dead space resulting from a canine surgical mastectomy and enable synthesis and stress reduction, thus improving the healing process. Some authors prefer not to use large amounts of suture material in order to decrease the inflammatory process. The main positive aspects of the walking suture are effectiveness in reducing stress and the obliteration of dead space. Possible drawbacks in the case of suture overuse are high probability of circulatory impairment of direct cutaneous vessel and of the subdermal plexus, as well as potential for seroma formation. Such problems, however, were not observed in the case described herewith, in which the walking suture had satisfactory results.

Open surgical management of auricular haematoma: incision, evacuation and mattress sutures.

A large variety of techniques have been used for auricular haematoma management. The open surgical management of auricular haematoma involves incision, evacuation and the obliteration of dead space using biodegradable mattress sutures. Our goal was to describe open surgical management for primary, recurrent and spontaneous auricular haematoma. Auricular haematoma patients who underwent open surgical management were prospectively audited (2010-2013). Information was collected on demographics, clinical presentation, aetiology, examination findings, previous interventions, details of open surgical management and post-operative follow up. In all, 12 male and 3 female patients with a mean age of 33 years (range 16-86 years) were evaluated. Contact sport injury was the most common aetiology. Ten patients had undergone previous unsuccessful interventions to treat auricular haematoma before open surgical management was performed. All patients were managed successfully without significant recurrence. One patient had a minor local reaccumulation which required reinsertion of a mattress suture. One elderly patient developed localised cellulitis which responded well to antibiotics. Open surgical management of auricular haematoma has been successful. The technique is simple and reliable, and can be accomplished in a clinical setting under local anaesthesia.

Abstract P2-13-28: Flap fixation reduces seroma in patients undergoing mastectomy: A significant implication for clinical practice

Abstract Background Seroma formation is a common complication following mastectomy for invasive breast cancer. Seroma formation can cause problems in wound healing and infection, thus leading to seroma aspirations and repeated visits to the out-patient clinic. The key to reducing seroma formations seems to partly lie in the obliteration of dead space. However, the techniques used to achieve this goal are subjects of much controversy and debate. Mastectomy flap fixation (FF) is achieved by reducing dead space volume using interrupted subcutaneous sutures. We hypothesized that obliteration of the dead space following mastectomy would significantly reduce seroma formation, resulting in fewer outpatient visits and seroma aspirations. This study, aiming to reduce seroma formation after mastectomy, is a retrospective study that compared conventional mastectomy with mastectomy and flap fixation. Methods All patients undergoing mastectomy due to invasive breast cancer were eligible for inclusion. From May 2012 – March 2013 all patients undergoing mastectomy in 2 hospitals were treated using flap fixation. The skin flaps were sutured on to the pectoral muscle using polyfilament absorbable sutures. The data was retrospectively analyzed and compared to a historical control group (HC) that was not treated using flap fixation (May 2011 – March 2012). In the HC group, only the skin was sutured. Closed suction drainage was applied to all patients in both groups. Results 180 patients were included; 92 in the FF group and 88 in the HC group. There were no significant differences in patient demographics. 36% of patients developed seroma in the group that underwent flap fixation; 59% of patients developed seroma in the historical control group (P=0.002). Seroma aspiration was performed in 15% of patients in the flap fixation group as opposed to 43% of patients in the control group (P<0.001). Multivariate analysis showed that the effect of flap fixation varied with the extent of surgery: whereas flap fixation reduced seroma formation in patients undergoing simple mastectomy or mastectomy with sentinel node recovery, FF did not reduce seroma formation in patients undergoing mastectomy with axillary lymph node dissection (i.e. modified radical mastectomy; P=0.04 for interaction. Effects of flap fixation on seroma formation stratified by operation type Historical ControlFlap fixationPMastectomy8/14 (57%)1/6 (17%)0.16Mastectomy and SN26/42 (62%)13/52 (25%)<0.001Modified Radical Mastectomy18/32 (56%)19/34 (56%)0.98 In contrast, flap fixation was associated with fewer seroma aspirations in all types of surgery (P=0.80 for interaction). Effects of flap fixation on seroma aspiration stratified by operation type Historical ControlFlap fixationPMastectomy6/14 (43%)1/6 (17%)0.35Mastectomy and SN19/42 (45%)7/52 (14%)0.001Modified Radical Mastectomy13/32 (41%)6/34 (18%)0.04 Conclusion Patients undergoing mastectomy flap fixation displayed a significant reduction in seroma formation and fewer patients were subjected to seroma aspiration. Patients undergoing flap fixation required fewer seroma aspirations. Flap fixation is an effective surgical technique in reducing dead space and therefore seroma formation in patients undergoing mastectomy for IBC. Citation Format: James Van Bastelaar, Arianne Beckers, Maarten Snoeijs, Yvonne Vissers. Flap fixation reduces seroma in patients undergoing mastectomy: A significant implication for clinical practice [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-28.

Free Gracilis Flap for Anatomic Reconstruction after Limb-sparing Sarcoma Resection

Limb-sparing surgery is considered as first choice in most patients with soft tissue sarcomas of the extremities. 5-year survival rates after limb soft tissue sarcoma resection have been promising in many specalised interdisciplinary centres. Quality of life as well as extremity function have thus become an integral aspect of the surgical management of soft tissue sarcomas of the extremities. We herein report on our experience in the anatomic reconstruction of the extremities following limb-sparing soft tissue sarcoma resection using microvascular gracilis muscle flap and skin grafts. Between 2012 and 2014 an anatomic reconstruction of the hand and foot using gracilis muscle flaps following limb-sparing sarcoma resection (leiomyosarcoma N=2, myxofibrosarcoma N=2, clear cell sarcoma N=1, myxoinflammatory fibroblastic sarcoma N=1, granular cell tumour N=1, pleomorphic sarcoma N=1) was performed in N=8 patients (4 females, 4 males), average age: 44 years (23-76 years), average follow-up time 444 days (98-820). In all patients successful defect coverage with unimpaired wound healing was achieved (adjunctive radiotherapy n=4). The tendon of the harvested gracilis muscle was used for anatomic reconstruction of consequently resected essential anatomic structures (extensor retinaculum n=1, flexor/extensor tendons n=4, extensor expansion n=2, tendon reinsertion n=1, proximal interphalangeal joint collateral ligament n=4, dorsal metatarsal ligament n=1). During follow-up neither local recurrence nor metastasis was observed. Reconstruction of multidirectional stability as well as restoring biomechanics and kinetics of the hand and foot should be considered during defect coverage and dead space obliteration management after sarcoma resection of the extremities. For reasons of sound options in anatomic extremity reconstruction with minimal donor site morbidity, the gracilis muscle flap excels in the field of limb-sparing sarcoma resection.

Soft-tissue reconstruction after total en bloc sacrectomy.

OBJECT Total en bloc sacrectomy is a dramatic procedure that results in extensive sacral defects. The authors present a series of patients who underwent flap reconstruction after total sacrectomy, report clinical outcomes, and provide a treatment algorithm to guide surgical care of this unique patient population. METHODS After institutional review board approval, data were collected for all patients who underwent total sacrectomy between 2002 and 2012 at The Johns Hopkins Hospital. Variables included demographic data, medical history, tumor characteristics, surgical details, postoperative complications, and clinical outcomes. All subtotal sacrectomies were excluded. RESULTS Between 2002 and 2012, 9 patients underwent total sacrectomy with flap reconstruction. Diagnoses included chordoma (n = 5), osteoblastoma (n = 1), sarcoma (n = 2), and metastatic colon cancer (n = 1). Six patients received gluteus maximus (GM) flaps with a prosthetic rectal sling following a single-stage, posterior sacrectomy. Four required additional paraspinous muscle (PSM) or pedicled latissimus dorsi (LD) fasciocutaneous flaps. Three patients underwent multistage sacrectomy with an anterior-posterior approach, 2 of whom received pedicled vertical rectus abdominis myocutaneous (VRAM) flaps, and 1 of whom received local GM, LD, and PSM flaps. Flap complications included dehiscence (n = 4) and infection (n = 1). During the 1st year of follow-up, 2 of 9 patients (22%) were able to ambulate with an assistive device by the 1st postoperative month, and 6 of 9 (67%) were ambulatory with a walker by the 3rd postoperative month. By postoperative Month 12, 5 of 9 patients (56%)-or 5 of 5 patients not lost to follow-up (100%)-were able to able to ambulate independently. CONCLUSIONS The authors' experience suggests that the GM and pedicled VRAM flaps are reliable options for softtissue reconstruction of total sacrectomy defects. For posterior-only operations, GM flaps with or without a prosthetic rectal sling are generally used. For multistage operations including a laparotomy, the authors consider the pedicled VRAM flap to be the gold standard for simultaneous reconstruction of the pelvic diaphragm and obliteration of dead space.

Toxicological evaluation of methanol leaves extract of <i>Vernonia bipontini</i> Vatke in blood, liver and kidney tissues of mice

Various medicinal plants have been studied using modern scientific approaches. These plants have a variety of properties and various biological components that can be used to treat various diseases. However, harmful effects of plants are common clinical occurrence. This study was designed to investigate toxicological assessment of acute and chronic methanol leaf extract of Vernonia bipontini Vatke (V.bipontini V) on blood, liver and kidney tissues of mice. Lethal dose (LD) at which 50% of experimental mice died and long term toxicity of methanolic leaf extract of V. bipontini V were determined. Some hematological and biochemical parameters were evaluated. Then, liver and kidney tissues of each animal were taken and processed for light microscopy. Almost all mice treated with 800mg/kg methanol leaf extract of V. bipontini V showed swellings on the left part of abdominal region related to location of spleen, mild diarrhea and enlargement of spleen. The LD50 of the methanol leaf extract of V. bipontini V was 2130.6±1.5mg/kg. Treatment with 800mg/kg body weight of methanol leaf extract significantly decreased body, liver and kidney weights, red blood cells (RBC), haemoglobin (Hgb), mean cell haemoglobin (Mch), Mchc, platelet and significantly increased serum aspartate transferance (AST), vatanine tranferance(ALT) and alkaline phosphate (ALP) levels while 400mg/kg dose had no effect on these parameters. The reduced organ weights did not correlate with loss of body weight at 800mg/kg of methanol leaf extract of the plant. Light microscope observations of liver tissue of mice treated with 800mg/kg of the methanol leaf extract revealed dilated sinusoids, nuclear enlargement, lots of bi-nucleation of hepatocytes, peripheral cramped chromatin, shrinkages (single cell death) of hepatocytes, fragmentation of hepatocytes while no histopathological changes were observed in liver and kidney of mice treated at 400mg/kg. Kidney tissue sections of mice did not show significant histopathological changes at 400mg/kg. However, at 800mg/kg kidney sections showed increased cellularity of glomerulus, urinary space obliteration and enlarged macula densa. This study suggests that the methanol leaf extract may have been phytotoxic to liver that resulted in a rise in serum AST, ALT and ALP levels.

Evaluation of the Quilting Technique for Reduction of Postmastectomy Seroma: A Randomized Controlled Study.

Background. Postmastectomy seroma causes patients' discomfort, delays starting the adjuvant therapy, and may increase the possibility of surgical site infection. Objective. To evaluate quilting of the mastectomy flaps with obliteration of the axillary space in reducing postmastectomy seroma. Methods. A randomized controlled study was carried out among 120 females who were candidates for mastectomy and axillary clearance. The intervention group (N = 60) with quilting and the control group without quilting. All patients were followed up routinely for immediate and late complications. Results. There were no significant differences between the two groups as regards the demographic characteristics, postoperative pathological finding, and the immediate postoperative complications. The incidence of seroma was significantly lower in the intervention group compared with the control group (20% versus 78.3%, P < 0.001). Additionally, the intervention group had a shorter duration till seroma resolution (9 days versus 11 days, P < 0.001) and a smaller volume of drainage (710 mL versus 1160 mL, P < 0.001) compared with the control group. Conclusion. The use of mastectomy with quilting of flaps and obliteration of the axillary space is an efficient method to significantly reduce the postoperative seroma in addition to significantly reducing the duration and volume of wound drainage. Therefore we recommend quilting of flaps as a routine step at the end of any mastectomy.

Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection: Erratum

Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection: Erratum

Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection

Objective The aim of the study was to detect the efficiency of dead space obliteration to reduce postmastectomy seroma formation, leading to early drain removal. Background Breast cancer is the most common female cancer worldwide. It accounts for 33% of female cancers at the National Cancer Institute (NCI). Primary operable breast cancer can be treated by either modified radical mastectomy or conservative breast surgery. Seroma represents the most important complication after modified radical mastectomy. Patients and methods Forty patients with primary operable breast cancer were included in this study from February 2013 to March 2014. They underwent modified radical mastectomy and were then divided into two groups: group A and group B. In group A patients, the wound was closed by means of the flap-fixation technique by continuous suturing of the upper flap to the pectoralis major muscle and lateral chest wall and suturing the pectoralis major muscle to the pectoralis minor muscle by four to six interrupted sutures using vicryl 2/0. In group B patients, the wound was closed by means of simple closure and application of a crepe bandage. Results There were significant differences between the two groups as regards the total amount of drained serous fluid ( P P P Conclusion The flap-fixation technique is a valuable technique for reducing seroma formation after mastectomy and axillary dissection.

Post-operative seromas: are they preventable with dead space obliteration?

Nickerson, Terry MD; Aho, Jonathon MD; Saint-Cyr, Michel MD; Farley, David R. MD, FACS Author Information

Tricks to decrease the suture line dehiscence rate during endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM).

ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long-term oncological results and better Quality of Life. The authors' policy is to close the residual defect, with possibly a higher risk of dehiscence from tension on the suture line. Aim is to evaluate if a modified technique may reduce the risk of dehiscence. The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients underwent ELRR by TEM with the authors' standard technique. In Group B, a subsequent series of 25 patients also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent prior to rectal wall closure. After suture completion, the rectal ampulla was stuffed with gauzes to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla. A transanal Foley catheter was positioned for gas evacuation. There were no significant differences in mean tumor distance from the anal verge, mean lesion diameter, mean operative time, and pathological staging between the two groups. Neoadjuvant radio-chemotherapy (n-RCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 patients (12%) and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6-7). None of these patients had undergone n-RCT. After ELRR by TEM, suture line dehiscence is presumably related to the wider size of the residual cavity. Obliteration of the residual perirectal space with hemostatic agent and by gauzes' introduction in the rectal ampulla may reduce the risk of postoperative perirectal abscess and thus reduce the suture line dehiscence rate.

Postoperative Local Morbidity and the Use of Vacuum-Assisted Closure After Complex Chest Wall Reconstructions With New and Conventional Materials

New materials (NM) such as titanium plates, cryopreserved grafts, and acellular collagen matrices are being increasingly used for chest wall reconstruction as a result of improved incorporation while maintaining structural stability and reduced need for removal from infected areas. Direct comparisons between NM and conventional materials (CM) in terms of local morbidity and need for prosthesis removal are lacking. Between January 2005 and July 2013, 109 procedures were performed to remove chest wall tumors in 86 patients. Of these, 32 underwent complex chest wall reconstructions owing to either recurrence, defect extension (greater than 3 ribs or >100 cm2) or local conditions (ie, previous irradiation or infection). New materials and CM (ie, polytetrafluoroethylene and methyl methacrylate) were used in 17 (53%) and 15 (47%) patients, respectively. Of the 32 patients included in the high complexity group, 23 patients did not exhibit any postoperative complications (72%). However, 9 patients (28%) underwent both a first and a second reoperation after a median interval of 4 months from the first procedure (range, 7 days to 60 months). Vacuum-assisted closure (VAC) was instituted in all patients as a means to control sepsis and facilitate space obliteration with healthy tissue. In 7 patients the reason for reintervention was local wound complications. In 4 of 7 patients, the prosthesis had to be removed (3 CM and 1 NM, 4.6% of the whole series; 12.5% in the high complexity group, 5.9% for NM and 20% for CM). The median time to complete chest wall healing after VAC in patients with local sepsis was 14 months (range, 5 to 60 months). All patients are currently alive and well except for 1 who died 11 months after complete chest wall healing as a result of dissemination of metastatic chondrosarcoma. At univariate analysis, predictors of overall and grade 2 or less morbidity according to the Common Terminology Criteria for Adverse Events version 4.0 were first (p=0.038) and second (p=0.015) redo operations. Conversely, patients with a body mass index of less than 25 kg/m2 (p=0.049) undergoing one (p=0.032) or two reconstructions (p=0.00047) with combined materials (p=0.00029) were more likely to experience local wound complications and require VAC. On multiple regression analysis, redo operations (first, p=0.032; second, p=0.00047) and the use of combined (synthetic and biologic) materials (p=0.0029) were confirmed to be related to an increased incidence of wound complications. Multiple redo operations after complex chest wall reconstruction performed with a combination of NM and CM may be associated with an increased incidence of local wound complications. Nevertheless, in these cases, the use of NM and VAC yielded a low rate (5.8% versus 20% with CM) of prosthesis removal while achieving complete wound healing.

Minimally invasive epicardial left ventricular lead placement in a case of massive pleural adhesion

BackgroundIn cases of intravenous placement failure of the left ventricular (LV) lead for cardiac resynchronisation therapy (CRT) and obliteration of the left pleural space, the alternative approach of transthoracic placement by video-assisted thoracoscopic surgery (VATS) is difficult and not commonly practiced.MethodsHere, we present a simple technique for transthoracic introduction of an epicardial LV lead using a wound retractor (ALEXIS®) in a patient with heart failure. This wound retractor enables atraumatic tissue retraction without rib spreading, an optimal direct view in the pleural space for surgical pleurolysis and a high degree of safety for the patient.ResultsNo perioperative complications occurred. The tube drainage was removed on the second postoperative day, and the patient was discharged on the third postoperative day.ConclusionsThe decided advantage of this new method is the lack of any need for rib spreading using a mechanical retractor. Especially in patients with a history of open-heart surgery (including internal mammary artery bypass grafting and/or revascularisation of the left lateral wall) or known pleural adhesions (e.g., pleuritis or lung operations), the described technique provides a rapid and save access with minimal surgical effort and greater safety.